Provider Demographics
NPI:1720064009
Name:RAINS, OTHA RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:OTHA
Middle Name:RAY
Last Name:RAINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 HAVEN VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7902
Mailing Address - Country:US
Mailing Address - Phone:314-603-3794
Mailing Address - Fax:
Practice Address - Street 1:11123 S TOWNE SQ
Practice Address - Street 2:SUITE E
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63123-7816
Practice Address - Country:US
Practice Address - Phone:314-487-4537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-06-03
Deactivation Date:2005-12-21
Deactivation Code:
Reactivation Date:2006-01-12
Provider Licenses
StateLicense IDTaxonomies
IL036-066358207P00000X
MOR3G19207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205710155Medicaid
MO953523211Medicare PIN
MO132110017Medicare PIN
MO205710155Medicaid
MO953523210Medicare PIN
ILA58185Medicare UPIN
MO953523213Medicare PIN